You are on page 1of 7

RESEARCH AND EDUCATION

Influence of remaining coronal tooth structure on fracture


resistance and failure mode of restored endodontically treated
maxillary incisors
Domingo Santos Pantaleón, DDS, MSD, PhD,a Brian R. Morrow, MS,b David R. Cagna, DMD, MS,c
Cornelis H. Pameijer, DMD, MScD, DSc, PhD,d and Franklin Garcia-Godoy, DDS, MS, PhDe

ABSTRACT
Statement of problem. Limited information is available on the effect of an incomplete ferrule because of the varying residual axial wall
heights and the volume of residual tooth structure on the fracture resistance of endodontically treated and restored maxillary incisors.
Purpose. The purpose of this in vitro investigation was to examine the effect of varying residual axial wall heights, residual coronal tooth
structure, and the absence of 1 proximal axial wall on the fracture resistance and failure mode of endodontically treated teeth restored with
metal posts.
Material and methods. Sixty intact human maxillary central incisors were divided into 6 groups (n=10): no ferrule (NF), 2-mm complete
ferrule (CF2), 2-mm (IF2), 3-mm (IF3), and 4-mm (IF4) incomplete ferrules missing a single interproximal wall, and a control group that
had a 6-mm incomplete ferrule (IF6). Cast metal post-and-cores were placed in all experimental specimens except for controls. Control
specimens received 1 interproximal cavity preparation extending to the root canal access and a composite resin restoration. Complete
metal crowns were then cemented on all specimens. Completed specimens were subjected to thermocycling (6000 cycles, 5 C/55 C)
followed by the immediate testing of fracture resistance. Failed specimens were sectioned buccolingually and evaluated to identify the
failure mode. The data were analyzed with an analysis of variance (ANOVA) and the Student-Newman-Keuls multiple comparison test (a=.05).
Results. An incomplete ferrule (IF2) with 1 interproximal wall missing had significantly reduced fracture resistance (697 N) compared with a
complete ferrule (932 N). An increase of 3 to 4 mm of remaining wall height improved fracture resistance, from 844 N (IF3) to 853 N (IF4).
Partial decementation was noticed in 8 NF and 5 IF2 specimens. IF3 and IF4 had no decementations. Radicular fractures and cracks (cata-
strophic failure) were observed in all IF2, IF3, and IF4, 9 CF2, and 6 NF specimens. In 7 specimens without posts (IF6, control), composite resin
foundation and/or coronal dentin fracture were observed and the failure was considered repairable.
Conclusions. The results of this in vitro study indicated that specimens with a 2-mm ferrule of uniform height were more resistant to fracture
than specimens with a 2-mm ferrule and 1 missing interproximal wall. An increased wall height of 3 or 4 mm was associated with a significant
increase in fracture resistance and can compensate for the missing interproximal wall. (J Prosthet Dent 2018;119:390-6)

Endodontically treated teeth are often more susceptible and the endodontic treatment itself.1,2 The choice of an
to fracture than are vital teeth because of the loss of appropriate restorative technique for endodontically
structural integrity secondary to the loss of enamel and treated maxillary incisors is determined by the amount of
dentin caused by caries, fractures, previous restorations, dental structure remaining, and by esthetic and

Partially funded by the Dominican Republic Ministry of Higher Education Science and Technology (National Fund for Innovation, Scientific and Technological
Development; code 2014-2A4-010).
a
Adjunct Professor, School of Dentistry, Autonomous University of Santo Domingo, Santo Domingo, Dominican Republic.
b
Research Associate, Department of Bioscience Research, College of Dentistry, University of Tennessee Health Science Center, Memphis, Tenn.
c
Professor and Associate Dean for Postgraduate Affairs, Director of the Advanced Prosthodontics Program, Department of Prosthodontics, College of Dentistry,
University of Tennessee Health Science Center, Memphis, Tenn.
d
Professor Emeritus, Department of Reconstructive Sciences, University of Connecticut, Farmington, Conn.
e
Professor and Senior Executive Associate Dean for Research, College of Dentistry, University of Tennessee Health Science Center, Memphis, Tenn; and Honorary
Professor, School of Dentistry, Autonomous University of Santo Domingo, Santo Domingo, Dominican Republic.

390 THE JOURNAL OF PROSTHETIC DENTISTRY

Downloaded for Anisha E A (anishaea@aims.amrita.edu) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on April 26, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
March 2018 391

partial ferrule with only the facial wall and concluded that
Clinical Implications a ferrule of 3 mm or more improved the fracture resis-
A ferrule missing a single interproximal axial wall tance compared with the control group with no ferrule.
Goto and Swift27 in unpublished research found no dif-
can be compensated for if more than 3 mm of the
ference in crown fracture resistance with or without
height of the remaining walls can be preserved. This
ferrule in the proximal walls. However, Naumann et al28
increases the fracture resistance of endodontically
reported that when the height of the incomplete ferrule
treated maxillary central incisors.
was 2 mm in the groups examined (buccal, proximal, and
lingual), the lowest fracture resistance was recorded in the
group with ferrule and no proximal walls. Tan et al,29 in a
functional considerations.3-7 Because endodontically
study in which the heights and configurations of the
treated teeth may have insufficient residual coronal
ferrule were varied, noticed that in specimens with a 2-
structure, the placement of a post-and-core is often
mm buccal and lingual height and proximal walls of 0.5
indicated.8-13 An important function of the post-and-core
mm, statistically significant lower fracture resistance was
is to retain the coronal restoration and favorably
recorded. However, Ng et al30 studied a partial 180 de-
distribute applied forces to the residual tissues.14-18 Peroz
grees in tooth circumference (buccal, proximal, and
et al19 conducted a systematic review and concluded that
lingual) with 2-mm residual walls. The group with the
the amount of residual tooth structure was more critical
proximal ferrule showed lower fracture resistance. Yang
than the post length in preventing tooth fracture.
et al31 suggested that more studies are needed to eluci-
Traditionally, the presence of a ferrule on sound tooth
date the relationship between the exact numbers of cor-
structure has been suggested.19,20 The ferrule effect is
onal walls in relation to restoration failures and concluded
developed by preparing residual coronal tooth structure
that the role of a ferrule is not totally understood.
to near-parallel axial walls traversing the circumference
This study evaluated the effect of a partial ferrule with 1
of the tooth. In so doing, placement of the definitive
missing interproximal axial wall and varying heights of the
complete crown is said to provide resistance to the
remaining walls on the fracture resistance of the tooth and
development of internal stress upon loading that can lead
also the failure mode in maxillary central incisors restored
to catastrophic failure.20 An appropriately developed
with cast metal post-and-cores. The first null hypothesis
ferrule may reduce the stress within the tooth structure,
was that the fracture resistance and the failure mode would
thus helping to maintain the integrity of the sealing
not be affected if a ferrule of 2 mm in height was present in
cement and also reducing the stress between the cement
3 walls with 1 interproximal wall missing. The second null
and the post-and-core.21
hypothesis was that increasing the height of the remaining
The need for a design for a complete ferrule has been
coronal walls to 3 or 4 mm would not be enough to
postulated,8,20 but there is no consensus regarding the
compensate for the 1 missing interproximal wall.
height of the axial walls. Most studies recommend a height
of 2 mm,19 while others suggest a minimum of 1.5 mm.22
MATERIAL AND METHODS
However, 1 study suggested a height of 1 mm if the core is
made of composite resin and a metal-free ceramic crown is Sixty intact periodontally compromised and recently
adhesively placed.23 Another study showed that the extracted maxillary central incisors were stored in 0.9%
higher the ferrule (3 mm), the higher the fracture resis- physiologic saline with 1% thymol at room temperature.
tance.24 In clinical practice, attaining a complete ferrule of The project received authorization from the National
even 2 mm of dentin is not always possible because of the Council of Bioethics in Health of the Dominican Re-
extent of a carious lesion or fracture. Orthodontic extrusion public. The teeth were examined under ×4 magnification
or crown lengthening to produce a complete ferrule is not and cleaned to remove all tissues and debris. Radio-
always possible either. Both of these methods have dis- graphs were obtained to verify the absence of fractures,
advantages because they may compromise periodontal internal root resorption, and endodontic filling material.
support and because lengthening the clinical crown can The root lengths (approximately 13.40 mm) and bucco-
affect esthetics by producing gingival margins at different lingual diameters (approximately 6.54 mm) at the
levels. Additionally, these treatments increase treatment cementum-enamel junction (CEJ) were measured with
time, patient discomfort, and treatment cost. digital calipers (Mitutoyo). The teeth were divided into 6
Information is sparse regarding the number and experimental groups of 10 teeth each (n=10). All teeth
height of the remaining walls of a partial ferrule and the received conventional endodontic treatment involving
influence they both have on the successful restoration of manual instrumentation with files of up to no. 40 K
severely compromised maxillary incisors.25 The few lab- (Dentsply Sirona), irrigation with 3% sodium hypochlo-
oratory and clinical studies available have shown incon- rite (ChloridCid; Ultradent Products, Inc), lateral
sistent results. Al-Wahadni and Gutteridge26 evaluated a condensation filling with gutta percha (Dentsply Sirona),

Santos Pantaleón et al THE JOURNAL OF PROSTHETIC DENTISTRY

Downloaded for Anisha E A (anishaea@aims.amrita.edu) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on April 26, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
392 Volume 119 Issue 3

Figure 1. Groups showing ferrule preparation, cast metal post-and-cores, and crown. A, Group NF No ferrule. B, Group CF2 2-mm-high complete ferrule.
C, Group IF2 2-mm-high incomplete ferrule missing proximal axial wall. D, Group IF3 3-mm-high incomplete ferrule missing proximal axial wall. E, Group
IF4 4-mm-high incomplete ferrule with 3-mm-high lingual wall and missing proximal axial wall. F, Group IF6 (control) 6-mm-high incomplete ferrule
missing proximal axial wall (no post).

and use of a sealing cement (AH26; Dentsply Sirona). 3-mm-high lingual wall; the 3-mm-high lingual wall was
The teeth were prepared by hand with rotary high-speed used to represent residual tooth structure realistically
diamond instruments (no. 6878-014; Brasseler) under after endodontic access), and IF6 (control; 6-mm-high
copious water irrigation. The anatomic crowns were incomplete ferrule missing an interproximal axial wall).
reduced according to the predetermined height for the All specimens received post-and-cores except for
experimental groups. For the interproximal cavities, a those in the control group, and all specimens received
coarse, round-end diamond rotary instrument (no. 6856- complete metal crowns. Post space preparation in the NF
012; Brasseler) was used to prepare the 3-mm buccolin- group was accomplished with a drill (no. 2 Peeso
gual width while establishing a coronal surface parallel to Reamer; Union Broach Co), removing 8 mm of gutta
the CEJ. The CEJ served as the circumferential reference percha as measured from the coronal remaining tooth
for the linear measurement of the remaining coronal structure. In other groups with 2-, 3-, and 4-mm-high
heights for each specimen.32 Specimens were then incomplete ferrules, 10, 11, and 12 mm of gutta percha
divided into the following 6 experimental groups (Fig. 1): were removed. This preparation routine permitted the
NF (no ferrule), CF2 (2-mm-high complete ferrule), IF2 fabrication of 8-mm posts for all specimens. Post spaces
(2-mm-high incomplete ferrule missing an interproximal were then gradually enlarged using no. 3 and 4 Peeso
axial wall), IF3 (3-mm-high incomplete ferrule missing Reamers (Union Broach Co). A direct technique was used
an interproximal axial wall), IF4 (4-mm-high incom- to fabricate post-and-core patterns. Post space contours
plete ferrule missing an interproximal axial wall and a were directly captured using plastic dowels with

THE JOURNAL OF PROSTHETIC DENTISTRY Santos Pantaleón et al

Downloaded for Anisha E A (anishaea@aims.amrita.edu) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on April 26, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
March 2018 393

autopolymerizing acrylic resin (DuraLay; Reliance Dental


Mfg Co), and a core was added. The patterns were
invested and cast in nickel-chromium alloy (VeraBond II;
AalbaDent), finished with rotary tungsten carbide
instrumentation (no.190 040; Komet), and airborne 50-
mm alumina particles at 410 kPa pressure. If casting de-
ficiencies were noted, new specimens were fabricated.
The post-and-cores were cemented with a self-adhesive
resin cement (Rely X U200 Automix; 3M ESPE)
following the manufacturer’s instructions. The post
spaces were irrigated with 3% sodium hypochlorite
(ChloridCid; Ultradent Products, Inc), followed by
distilled water, and dried with paper points (Coltène).
The cement was introduced into the post space using
dispensing tips provided by the manufacturer. The post-
and-cores were placed using slight repetitive torsional
movements to reduce hydraulic pressure and prevent air
entrapment. Constant finger pressure consistent with
clinical practice was applied until the initial setting
occurred, followed by at least 6 minutes of further bench
set to permit complete polymerization. Excess cement
was removed with a scaler. In the IF6 group, the cavity Figure 2. Failure modes based on Fokkinga et al33: (1) complete
walls were etched with 37% phosphoric acid (Prime decementation of post-and-core and crown, (2) partial decementation
Dental) for 15 seconds, rinsed with an air/water spray, of post-and-core and/or crown, (3) fracture composite resin
and gently air-dried. A thin layer of adhesive (Single foundation-coronal dentin, (4) dislodgement of lingual cervical margin
crown, (5) oblique fracture, (6) horizontal fracture, (7) propagation
Bond Universal; 3M ESPE) was applied with a micro-
fracture subosseous, and (8) propagation fracture supra-osseous. Level
brush, air-dispersed, and light-polymerized for 40 sec-
of bone indicated with asterisk.
onds (VALO Cordless; Ultradent Products, Inc). The
cavity was then incrementally filled with a composite cementation, all specimens were thermocycled in distilled
resin (Z350 Filtek; 3M ESPE), and each increment was water (6000 cycles; 5 C/55 C, 2-minute dwell time) to
light-polymerized for 20 seconds. simulate approximately 5 years of service in the oral
The coronal contours were refined using diamond cavity.28 The roots were embedded in autopolymerizing
rotary instruments (no. 6878-014; Brasseler) under acrylic resin (SamplKwich; Buehler) leaving 2 mm of the
copious water irrigation, resulting in the following coronal coronal root surface exposed to imitate osseous support.
preparation parameters: a preparation height of 6 mm, Each specimen was tested for fracture resistance using
chamfer finish line at the CEJ, 1.5-mm buccal reduction, a universal testing machine (5567; Instron). Compressive
1.0-mm interproximal and lingual reductions, and 2-mm force was applied to the stop on the lingual surface of the
incisal reduction. After 1 layer of die spacer (Die Spacer; crowns and directed at a 45-degree angle to the longi-
Keystone Industries), a complete contour wax pattern was tudinal axis of the tooth at a crosshead speed of 0.5 mm/
created directly on 1 specimen. This pattern was 8 mm min until fracture. This loading geometry simulated the
high and had a circumferential thickness of approximately potential occlusal forces in a Class I occlusion.32
1 to 1.5 mm. A rectangular-shaped stop with a central The failure mode of the specimens was evaluated by
concavity was added 2 mm apical to the incisal edge on embedding the fractured specimens in autopolymerizing
the lingual surface. This stop facilitated loading during acrylic resin (SamplKwich; Buehler), followed by
fracture resistance testing. The completed crown pattern sectioning in a buccolingual direction with a low-speed
was used to generate a mold (Putty Normal Set, Elite HD; diamond wafering blade under water irrigation (IsoMet
Zhermack), which was used to fabricate replica crown 5000; Buehler). The sections were photographed with a
patterns in wax for all specimens. The wax patterns were stereomicroscope (Discovery.V8; Carl Zeiss) at ×15
invested, eliminated, and cast in nickel-chromium alloy magnification. Based on Fokkinga et al,33 the mode of
(VeraBond II; AalbaDent). The castings were inspected failure (Fig. 2) was characterized as follows: complete
under ×4 magnification for defects and a new one fabri- decementation of the post-and-core and crown; partial
cated if deficiencies were observed. The castings were decementation of the post-and-core and/or crown; frac-
finished and cemented with zinc phosphate cement ture of the composite resin foundation-coronal dentin;
(Fleck’s; Mizzy), mixed according to the manufacturer’s dislodgement of the lingual cervical margin crown; trajec-
instructions, and held under finger pressure.22 After tory of root fracture (oblique or horizontal); propagation

Santos Pantaleón et al THE JOURNAL OF PROSTHETIC DENTISTRY

Downloaded for Anisha E A (anishaea@aims.amrita.edu) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on April 26, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
394 Volume 119 Issue 3

Table 1. Fracture load (N) of different groups Table 2. Failure modes


Group Mean ±SD Experimental Group
NF No ferrule 494 ±110a Failure Mode NF CF2 IF2 IF3 IF4 IF6
CF2 2-mm-high complete ferrule 932 ±236a,b 1 e Complete decementation of post-and-core 1
IF2 2-mm-high incomplete ferrule missing proximal axial wall 697 ±165a,b and crown

IF3 3-mm-high incomplete ferrule missing proximal axial wall 844 ±143a 2 e Partial decementation of post-and-core 8 1 5 7
and/or crown
IF4 4-mm-high incomplete ferrule with 3-mm-high lingual wall 853 ±115a
and missing proximal axial wall 3 e Fracture composite resin foundation- 7
coronal dentin
IF6 6-mm-high incomplete ferrule missing proximal axial wall 896 ±210a
4 e Dislodgement of lingual cervical margin 4 6 3 7
a,b
Statistically significant differences (P<.05). crown
5 e Oblique fracture 1 5 7 6 3 1
of fracture (subosseous, supra-osseous); favorable 6 e Horizontal fracture 1 4 3 4 7 2
outcome (failure permits restoration of the tooth); and 7 e Propagation fracture subosseous 4 9 10 10 10
unfavorable outcome (failure does not permit predictable 8 e Propagation fracture supra-osseous 1 3 6 6 4 3
restoration). The data were analyzed with ANOVA and the Failure favorable/unfavorable total 4/6 1/9 0/10 0/10 0/10 7/3
Student-Newman-Keuls multiple comparison test Based on Fokkinga et al, 2004.33
(a=.05).
specimens with a 2-mm-circumferential ferrule (CF2).
RESULTS The higher values of fracture resistance in CF2 (932 N)
compared with IF2 (697 N) specimens showed that the
Fracture resistance data recorded for each group is
resistance of the tooth was directly related to the amount
illustrated in Table 1. One-way ANOVA revealed a sta-
of remaining dentin, which corroborates the findings of
tistically significant difference (P<.05) among the groups.
other studies.10,13 A 2-mm height with parallel walls and
The Student-Newman-Keuls multiple comparison sta-
a 360-degree circumference is better than a 0-mm
tistical tests indicated statistically significant differences
ferrule19,20 and partial ferrule designs with 2-mm
between CF2 and IF2 (P<.05) also NF and all other
height in the remaining walls.28-30 This indicates that
treatment groups CF2 (P<.05), IF2 (P<.05), IF3 (P<.05),
the amount of residual dentin after endodontic treatment
IF4 (P<.05), and IF6 (P<.05). Significant differences were
seems to be a crucial factor for the tooth’s prognosis.9,19
not identified between the other group combinations.
The statistically significant difference between the CF2
Means and standard deviations are listed in Table 1.
and IF2 groups suggests that the lack of 1 interproximal
Regarding failure mode, the researchers identified
wall increases the displacement of the crown in a lingual
partial decementation of the post-and-core and/or crown
direction, reducing the antirotational capacity of the
in 8 specimens in NF, partial decementation of the post-
ferrule.15 The clinical implication of the results in IF2
and-core in 1 specimen in CF2 and 5 specimens in IF2,
specimens must be interpreted with caution, because the
and partial decementation of the core-crown in 7 speci-
forces that caused failures in this study were much higher
mens in IF6. Fracture of the composite resin foundation-
than those exerted on a natural maxillary central incisor
coronal dentin and dislodgement of the crowns at the
of individuals in maximum occlusion force (between 140
lingual margin were observed in 7 IF6 specimens. The
and 200 N).34
trajectory and location of the root fracture varied, with
The second null hypothesis, that an increase in height
oblique, cervical third fractures and horizontal, middle
of the remaining walls to 3 to 4 mm does not compensate
third fractures occurring most frequently. Subosseous
for the lack of 1 proximal wall in increasing the resistance
crack propagation occurred in almost all specimens with
of the tooth, was also rejected. The fracture resistance IF3
post-and-cores and crowns. Failures deemed to be pre-
(844 N) and IF4 (853 N) specimens rendered failure loads
venting future predictable restorations were recorded for
close to the resistance values of CF2 specimens (932 N).
most of the specimens with post-and-cores, except for 4
The results of the present study show that the fracture
NF specimens and 1 CF2 specimen. Seven failures in the
resistance in the 3-wall ferrule design of 3 to 4 mm of
IF6 group were considered restorable (Table 2). Failures
coronal height is higher than that of the 3-wall ferrule
(favorable) were considered restorable if enough dentin
design of 2 mm in height. This suggests that a partial
remained to restore the tooth after modifying the
ferrule can be more effective if 3 to 4 mm in height of the
preparation.
remaining dentin walls can be preserved.15
In both the IF3 and IF4 groups, the height of the
DISCUSSION
lingual wall was 3 mm, but with different heights in the
The first null hypothesis that the fracture resistance buccal and interproximal remaining walls (3 mm in IF3
would not be affected when a ferrule of 2 mm in coronal and 4 mm in IF4). Statistical similarity in load to failure
height in 3 walls was present was rejected. The fracture for the incomplete ferrule of groups IF3 and IF4 appears
resistance of IF2 was negatively affected compared with to confirm results from other studies,13,30 and indicates

THE JOURNAL OF PROSTHETIC DENTISTRY Santos Pantaleón et al

Downloaded for Anisha E A (anishaea@aims.amrita.edu) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on April 26, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
March 2018 395

that the lingual wall performs an important role in CONCLUSIONS


resistance to fracture in endodontically treated teeth.
Within the limitations of this in vitro study, the following
That effectiveness is logical, because the lingual wall acts
conclusions were drawn:
as the main counterforce to the occlusal load. A finite
element analysis study suggested that when the height of 1. Restored endodontically treated maxillary central
the ferrule is higher, it becomes more efficient in incisors with a 2-mm-high complete ferrule were
reducing the axial arm of the rotation force.15 This re- more resistant to fracture than were teeth with a 2-
duces the potential decementation of the post/core/ mm-high incomplete ferrule missing 1 proximal
crown complex. This, therefore, could explain the partial axial wall (P<.05).
decementation observed in 5 specimens from the IF2 2. Increasing the wall height to 3 and 4 mm was
group, while in the IF3 and IF4 groups no decementation associated with significant increases in fracture
was observed. No significant statistical differences were resistance and can compensate for the missing 1
detected between the fracture resistance in groups CF2, proximal wall.
IF3, and IF4 compared with IF6. This result possibly ex-
plains why the indication of a post for the retention and
REFERENCES
support of a complete crown restoration is not necessary
when sufficient dentin remains. This study’s data agree 1. Dietschi D, Duc O, Krejci I, Sadan A. Biomechanical considerations for the
restoration of endodontically treated teeth: A systematic review of the liter-
with the observations of other studies.3 ature: Part II. Evaluation of fatigue behavior, interfaces, and in vivo studies.
Assessment of the failure mode revealed that, in Quintessence Int 2008;39:117-29.
2. Reeh ES, Messer HH, Douglas WH. Reduction in tooth stiffness as a result of
most specimens with post-and-cores, catastrophic fail- endodontic and restorative procedures. J Endod 1989;15:512-6.
ure resulted in root fracture, except in 4 NF specimens 3. Heydecke G, Butz F, Strub JR. Fracture strength and survival rate of
endodontically treated maxillary incisors with approximal cavities after
and 1 CF2 specimen in which the failure was repairable. restoration with different post and core systems: an in-vitro study. J Dent
Microscopic evaluation of sections of selected speci- 2001;29:427-33.
4. Signore A, Benedicenti S, Kaitsas V, Barone M, Angiero F, Ravera G. Long-
mens allowed precise detection of the type of failure. term survival of endodontically treated, maxillary anterior teeth restored with
Partial decementation of the post-and-core and/or either tapered or parallel-sided glass-fiber posts and full-ceramic crown
coverage. J Dent 2009;37:115-21.
crown occurred in 8 NF specimens and 5 IF2 specimens. 5. Valdívia AD, Raposo LH, Simamoto-Junior PC, Novais VR, Soares CJ. The
These findings are also in agreement with other effect of fiber post presence and restorative technique on the biomechanical
behavior of endodontically treated maxillary incisors. J Prosthet Dent
studies.12 In all IF2, IF3, and IF4 specimens and 9 CF2 2012;108:147-57.
specimens, crack propagation was observed below the 6. Abduljawad M, Samran A, Kadour J, Al-Afandi M, Ghazal M, Kern M. Effect
of fiber posts on the fracture resistance of endodontically treated
simulated bone level. This can be attributed to the high anterior teeth with cervical cavities: An in vitro study. J Prosthet Dent
modulus of elasticity of the Ni-Cr16 alloy that concen- 2016;116:80-4.
7. Abduljawad M, Samran A, Kadour J, Karzoun W, Kern M. Effect of fiber
trates elevated stress through the post-and-core in the posts on the fracture resistance of maxillary central incisors with class III
cervical third, middle, and apical canal walls and is restorations: An in vitro study. J Prosthet Dent 2017;118:55-60.
8. Morgano SM. Restoration of pulpless teeth: application of traditional prin-
responsible for catastrophic radicular oblique and hori- ciples in present and future contexts. J Prosthet Dent 1996;75:375-80.
zontal fractures.12 9. Bitter K, Noetzel J, Stamm O, Vaudt J, Meyer-Lueckel H, Neumann K, et al.
Randomized clinical trial comparing the effects of post placement on failure
However, in 7 specimens without a post (IF6), the rate of postendodontic restorations: preliminary results of a mean period of
fracture occurred in the composite resin foundation- 32 months. J Endod 2009;35:1477-82.
10. Zhi-Yue L, Yu-Xing Z. Effects of post-core design and ferrule on fracture
coronal dentin region, making it a repairable failure. resistance of endodontically treated maxillary central incisors. J Prosthet Dent
These findings are in accordance with those of Pierris- 2003;89:368-73.
11. Gu XH, Kern M. Fracture resistance of crowned incisors with different post
nard et al.17 Furthermore, crown displacement in the systems and luting agents. J Oral Rehabil 2006;33:918-23.
lingual area was observed in 7 IF6 specimens, corrobo- 12. Hayashi M, Takahashi Y, Imazato S, Ebisu S. Fracture resistance of
rating a finite element analysis study showing that when pulpless teeth restored with post-cores and crowns. Dent Mater 2006;22:
477-85.
an incisor is subjected to a masticatory load, the 13. Zhang YY, Peng MD, Wang YN, Li Q. The effects of ferrule configuration on
the anti-fracture ability of fiber post-restored teeth. J Dent 2015;43:117-25.
maximum concentration of tensional stress is concen- 14. Assif D, Gorfil C. Biomechanical considerations in restoring endodontically
trated on the lingual surface.18 In a retrospective clinical treated teeth. J Prosthet Dent 1994;71:565-7.
15. Ichim I, Kuzmanovic DV, Love RM. A finite element analysis of ferrule design
study on maxillary central incisors restored with fiber on restoration resistance and distribution of stress within a root. Int Endod J
posts and ceramic crowns, while considering the influ- 2006;39:443-52.
16. Assif D, Oren E, Marshak BL, Aviv I. Photoelastic analysis of stress transfer
ence of residual coronal dentin, the survival was longer by endodontically treated teeth to the supporting structure using different
for teeth that had 3 or 4 coronal walls.4 The data reported restorative techniques. J Prosthet Dent 1989;61:535-43.
here corroborated these findings. 17. Pierrisnard L, Bohin F, Renault P, Barquins M. Corono-radicular recon-
struction of pulpless teeth: a mechanical study using finite element analysis.
A limitation of this study is that only a static, rather J Prosthet Dent 2002;88:442-8.
18. Ho MH, Lee SY, Chen HH, Lee MC. Three-dimensional finite element
than a clinically more relevant dynamic load, was analysis of the effect of posts on stress distribution in dentine. J Prosthet Dent
applied. However, as with any laboratory study that 1994;72:367-72.
19. Peroz I, Blankenstein F, Lange KP, Naumann M. Restoring endodontically
involves numerous steps to produce test specimens, treated teeth with posts and cores - a review. Quintessence Int 2005;36:
unavoidable variations will always occur. 737-46.

Santos Pantaleón et al THE JOURNAL OF PROSTHETIC DENTISTRY

Downloaded for Anisha E A (anishaea@aims.amrita.edu) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on April 26, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.
396 Volume 119 Issue 3

20. Stankiewicz NR, Wilson PR. The ferrule effect: a literature review. Int Endod J 31. Yang A, Lamichhane A, Xu C. Remaining coronal dentin and risk of fiber-
2002;35:575-81. reinforced composite post-core restoration failure: a meta-analysis. Int J
21. Sorensen JA, Engelman MJ. Ferrule design and fracture resistance of Prosthodont 2015;28:258-64.
endodontically treated teeth. J Prosthet Dent 1990;63:529-36. 32. Varvara G, Perinetti G, Dilorio D, Murmura G, Caputi S. In vitro evaluation of
22. Libman WJ, Nicholls JI. Load fatigue of teeth restored with cast posts and fracture resistance and failure mode of internally restored endodontically
cores and complete crowns. Int J Prosthodont 1995;8:155-61. treated maxillary incisors with differing heights of residual dentin. J Prosthet
23. Ma PS, Nicholls JI, Junge T, Phillips KM. Load fatigue of teeth with different Dent 2007;98:365-72.
ferrule lengths, restored with fiber posts, composite resin cores, and all- 33. Fokkinga WA, Kreulen CM, Vallittu PK, Creugers NH. A structured analysis
ceramic crowns. J Prosthet Dent 2009;102:229-34. of in vitro failure loads and failure modes of fiber, metal, and ceramic post-
24. Pereira JR, de Ornelas F, Conti PC, do Valle AL. Effect of a crown ferrule on and-core systems. Int J Prosthodont 2004;17:476-82.
the resistance of endodontically-treated teeth restored with prefabricated 34. Tortopidis D, Lyons MF, Baxendale RH, Gilmour WH. The variability of bite
posts. J Prosthet Dent 2006;95:50-4. force measurement between sessions, different positions within dental arch.
25. Jotkowitz A, Samet N. Rethinking ferruleea new approach to an old dilemma. J Oral Rehab 1998;25:681-6.
Br Dent J 2010;209:25-33.
26. Al-Wahadni A, Gutteridge DL. An in vitro investigation into the effects of
retained coronal dentine on the strength of a tooth restored with a cemented Corresponding author:
post and partial core restoration. Int Endodon J 2002;35:913-8. Dr Domingo Santos Pantaleón
27. Goto Y, Swift E Jr. Ferrules for endodontically treated teeth. J Esthet Rest Calle Elipse 7, Apto 1A, Urbanización Fernández
Dent 2009;21:292-3. Santo Domingo
28. Naumann M, Preuss A, Rosentritt M. Effect of incomplete crown ferrules on DOMINICAN REPUBLIC
load capacity of endodontically treated maxillary incisors restored with fiber Email: dsantospantaleon@gmail.com
posts, composite build-ups, and ceramic crowns: an in vitro evaluation after
chewing simulation. Acta Odontol Scand 2006;64:31-6. Acknowledgments
29. Tan PL, Aquilino SA, Gratton DG, Stanford CM, Tan SC, Johnson WT, et al. The authors thank predoctoral students Julio Santos Olivares and Kenny Tejada
In vitro fracture resistance of endodontically treated central incisors Serrano, School of Dentistry, Autonomous University of Santo Domingo, for their
with varying ferrule heights and configurations. J Prosthet Dent 2005;93: assistance in the preparation of specimens; and Dr Hira Iftikhar, Bioscience
331-6. Research Center, College of Dentistry, University of Tennessee Health Science
30. Ng CC, Dumbrigue HB, Al-Bayat ML, Griggs JA, Wakefield CH. Influence of Center, Memphis, Tenn, for her support.
remaining coronal tooth structure location on the fracture resistance of
restored endodontically treated anterior teeth. J Prosthet Dent 2006;95:290-6. Copyright © 2017 by the Editorial Council for The Journal of Prosthetic Dentistry.

THE JOURNAL OF PROSTHETIC DENTISTRY Santos Pantaleón et al

Downloaded for Anisha E A (anishaea@aims.amrita.edu) at Amrita Institute of Medical Science and Research Centre from ClinicalKey.com by Elsevier on April 26, 2019.
For personal use only. No other uses without permission. Copyright ©2019. Elsevier Inc. All rights reserved.